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An overbite of the upper incisors creates a shearing action as these teeth slide past one another purchase 20mg pariet with mastercard gastritis diet vs regular. Masticated food is mixed with saliva generic 20mg pariet overnight delivery gastritis gi bleed, which initiates chemical digestion and aids swallowing. A tooth consists of an exposed crown, which is supported by a neck that is anchored firmly into the jaw by one or more roots (fig. The roots of teeth fit into sockets, called den- tal alveoli, in the alveolar processes of the mandible and maxil- and fasten the tooth in its dental alveolus. Each socket is lined with a connective tissue periosteum, (gum) is the mucous membrane surrounding the alveolar specifically called the periodontal membrane. Digestive System © The McGraw−Hill Anatomy, Sixth Edition Body Companies, 2001 Chapter 18 Digestive System 645 can be tasted. Saliva also contains starch-digesting enzymes and Enamel lubricating mucus, which aids swallowing. Saliva is secreted con- tinuously, but usually only in sufficient amounts to keep the mu- cous membranes of the oral cavity moist. Dentin Numerous minor salivary glands are located in the mucous membranes of the palatal region of the oral cavity. However, Dental pulp three pairs of salivary glands that lie outside the oral cavity pro- (in pulp cavity) duce most of the saliva, which is transported to the oral cavity via salivary ducts. The three major pairs of extrinsic salivary glands Gingiva are the parotid, submandibular, and sublingual glands (fig. It is positioned below and in front of the auricle of the membrane ear, between the skin and the masseter muscle. Saliva produced in the parotid gland drains through the parotid (Stensen’s) duct. Root The parotid duct parallels the zygomatic arch across the masseter canal Dental alveolus muscle, pierces the buccinator muscle, and empties into the oral Cementum cavity opposite the second upper molar. It is the parotid gland that becomes infected and swollen with the mumps. Root The submandibular gland lies inferior to the body of the mandible, about midway along the inner side of the jaw. Each sublingual gland contains several small sublingual ducts (Rivinus’ ducts) that empty into the floor of the mouth in an area posterior to the papilla of the submandibular duct. Enamel is composed Two types of secretory cells, serous and mucous cells, are primarily of calcium phosphate and is the hardest substance in the found in all salivary glands in various proportions (fig. Serous cells produce a watery fluid containing digestive enzymes; The pulp cavity contains the pulp, which is composed of connec- mucous cells secrete a thick, stringy mucus. Cuboidal epithelial tive tissue with blood vessels, lymph vessels, and nerves. Sympathetic impulses stimulate the receives nourishment through vessels traversing the apical fora- secretion of small amounts of viscous saliva. Proper nourishment is particularly important during embry- stimulation causes the secretion of large volumes of watery saliva. The diet of the mother should contain an Physiological responses of this type occur whenever a person abundance of calcium and vitamin D during pregnancy to ensure sees, smells, tastes, or even thinks about desirable food. Refluxed stomach acids also destroy tooth enamel and con- Pharynx stant vomiting, as in the eating disorder bulimia nervosa, contributes to the development of dental caries. The rate of tooth decay decreases after age 35, but then ing the oral and nasal cavities to the esophagus and larynx. Periodontal diseases result from plaque or tartar buildup at the gum line. This buildup pulls the pharynx has both digestive and respiratory functions. The sup- gum away from the teeth, allowing bacterial infections to develop. Saliva functions as a solvent in Wharton’s duct: from Thomas Wharton, English physician, 1614–73 cleansing the teeth and dissolving food molecules so that they Rivinus’ ducts: from August Quirinus Rivinus, German anatomist, 1652–1723 Van De Graaff: Human VI. Digestive System © The McGraw−Hill Anatomy, Sixth Edition Body Companies, 2001 646 Unit 6 Maintenance of the Body Accessory salivary gland Tongue Accessory salivary gland Lingual frenulum Parotid gland Opening of submandibular duct Sublingual ducts Parotid duct Masseter muscle Sublingual gland Submandibular Submandibular gland duct Mandible (cut) FIGURE 18. Mucous cells Intralobular parotid duct Lumen of Seromucous submandibular acini intralobular duct Serous cells (a) (b) Mucous cells Serous cells Intralobular (c) sublingual duct FIGURE 18.

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Many times purchase pariet 20 mg visa chronic gastritis fever, I have testified at trial concerning motor vehicular accidents (and others) by whichever side needs and asks for me cheap pariet 20mg lymphocytic gastritis definition. When asked what you have read or studied in preparation for this trial, have a list of all depositions you have reviewed, a list of journals that you regularly read, and anything else that is out of the ordinary. This is aside from the time spent in meetings, continuing medical education, conferences, and rounds. I am especially aware of the importance of knowledge of the history of medicine. I am also managing editor of the Journal of the American Board of Quality Assurance and Utilization Review Physicians. The answers to this question are as follow: • Medicine, like law, is a very esoteric discipline, and the various legal experts may not be able (without assistance from other disciplines) to rank matters according to meaningful, objective, and just priorities. As such, he or she should be able to clarify many issues that are not immediately clear. This keeps most of us honest and helps to facilitate the quest for truth and justice. We are all aware that imperfections and misunderstandings may dis- tort the pure intent of seeking justice, and sadly, we have to note that some experts are easily swayed by prejudice in favor of the client of the lawyer who engaged them. This can often be ameliorated by the oppos- ing attorney, or the opposing expert, so that at least both viewpoints are clearly present at trial. The right of decision making belongs to the jury alone and not to the expert. The expert witness need not be intimidated by his or her lack of knowledge of the law. The expert who sees him or herself as a “gladiator” or a “gun for hire” will not usually be effective in the pursuit of justice, although he or she may well be able to sway a jury. Probably the last and least desirable quality of an expert witness is the irrepressible desire to win at all costs and by whatever distortion is necessary. If this appears to be the case, then the expert’s testimony will be severely and deservedly discounted. Chapter 4 / Physician As a Witness 51 What ethic serves to guide the expert witness? Very simply, it is the ninth commandment: “Thou shalt not bear false witness against thy neighbor. You should leave the witness stand with everyone’s respect, including and especially your own. Chapter 5 / Discovery and Deposition 53 5 The Judicial Process Discovery and Deposition Jonathan I. Epstein, MD SUMMARY This chapter explores the nature and conduct of pretrial discovery and the deposition process from the physician’s point of view. Practical suggestions for witness preparation and guides to recog- nition of the methods, procedures, and goals of the plaintiff attor- ney are presented. Courtroom deportment is discussed, and model questions and appropriate responses are included. During written interrogatories, the plain- tiff attorney will pose a limited number of detailed written questions for you (in conjunction with your attorney) to reply to under oath (1,2). Another aspect to discovery is oral interrogation, also known as a deposition. Well before the deposition, the defendant should insist on a meeting with his or her lawyer. Also, if something new or unexpected arises, there will be time to deal with it. It is reasonable to have someone from your From: Medical Malpractice: A Physician’s Sourcebook Edited by: R. It is important to note that everything you write is discoverable except for direct communications to your lawyer.

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This func- nitive functions order 20mg pariet with mastercard gastritis diet 22, such as learning and tion makes possible reflex action such remembering buy 20mg pariet otc diet for gastritis sufferers, feeling emotion, reasoning, 25 26 CHAPTER 2 CONDITIONS OF THE NERVOUS SYSTEM: PART I generating and relaying thoughts, and dis- (Figure 2–1). After neurotransmitters are playing the general personality traits that released, they are either taken up again by are characteristic of how each individual the neuron or destroyed. When transmitting impulses Nerve Cells within the central nervous system, these bundles are referred to as tracts. Those Specialized cells called neurons are the bundles located outside of the central functional units of the nervous system. They consist of a cell body and The Central Nervous System processes or nerve fibers that extend be- yond the cell body. In most cases a single The central nervous system is made up of long nerve fiber, called an axon, conducts the brain and spinal cord, which are both nerve impulses (and information) away protected by bony coverings. Fibers that carry informa- brane, lying most closely to the bony tion from parts of the body to the brain covering of the brain and spinal cord. Information is mater and the inner surface of the bony passed from neuron to neuron by both covering is the epidural space. The elec- between the dura mater and arachnoid trical impulse, which has been picked up membrane is the subdural space, and the by the dendrites, is passed through the cell space between the arachnoid membrane body to the axon. At the tip of the axon tected and cushioned by cerebrospinal are tiny processes that release chemicals fluid (CSF), which is formed by specialized known as neurotransmitters, which, through capillaries called the choroid plexus in inner chemical means, transfer the impulse chambers within the brain called ventricles. This space It circulates from the ventricles into the is called the synapse. The electrical im- subarachnoid space; then it flows to the pulse, through the vehicle of neurotrans- back of the brain, down around the spinal mitters, then moves to the next neuron’s cord, and then flows back to the brain, dendrites, and the process begins again where it is reabsorbed into the blood Normal Structure and Function of the Nervous System 27 Dendrite Axon Direction of Nerve Impulse Synaptic Knob Synaptic Cleft Dendrites Axon Figure 2–1 The Neuron. The toxins, are prevented from crossing into amount of CSF produced and absorbed is the brain. It is which substances can move from the called white matter because of its whitish blood into the brain. Small segments of gray potentially harmful substances, such as matter are also embedded deep within cer- 28 CHAPTER 2 CONDITIONS OF THE NERVOUS SYSTEM: PART I tain parts of the white matter of the brain. Gray matter consists of groups of neuron Each hemisphere has centers for receiving cell bodies. It is called gray matter because information and for initiating responses. The gray mat- The left hemisphere mostly receives infor- ter of the brain receives, sorts, and process- mation from and sends information to the es nerve messages, and the gray matter of right side of the body, and the right hemi- the spinal cord serves as a center for reflex sphere mostly receives information from action (automatic response to stimuli). Deep within the cerebral hemi- The Brain spheres are groups of gray matter called basal ganglia, which are part of the The brain, which is directly connected extrapyramidal system. In addition, it is the site of Basal ganglia help to maintain contractile consciousness and intellectual function. The basal ganglia is covered with a thin outer layer of gray also play a role in enabling individuals to matter called the cortex, which contains react swiftly, appropriately, and automat- billions of nerve cells. The cortex has three ically to stimuli that demand an immedi- specialized areas that serve three major ate response, such as, after tripping, functions: enabling the individual to adjust move- ment in order to avoid a fall. The motor cortex coordinates voluntary Each hemisphere of the cerebrum is movements of the body. The frontal lobe is recognition or perception of sensory located in the front of each hemisphere stimuli, such as touch, pain, smell, and contains motor areas that initiate vol- taste, vision, and hearing. The associational cortex is involved in ments, such as those involved in writing. The cerebrum is divided into two halves, The parietal lobe is located in the middle called hemispheres: the right hemisphere of each hemisphere and is primarily the and the left hemisphere. The two hemi- sensory area, integrating and interpreting spheres communicate with each other. Some memory functions specific areas within them are bundles of are also located in the parietal lobe, espe- Normal Structure and Function of the Nervous System 29 Subarachnoid Parietal Lobe Space Pia Mater Wernicke’s Area Arachnoid Frontal Membrane Lobe Broca’s Subdural Area Space Ventricles Epidural Space Temporal Dura Lobe Mater Occipital Brain Lobe Stem Cerebellum Figure 2–2 The Brain. The temporal lobe is located is the major area responsible for receptive under the frontal and parietal lobes and function, or the ability to integrate visual is primarily responsible for the interpreta- and auditory information in order to tion of and distinction between auditory understand a communication received.

An NO-evoked release of glutamate discount pariet 20 mg free shipping gastritis ice cream, CGRP and substance P may operate as a positive feedback system to further generate wind-up and centrally mediated hyperalgesia order pariet 20mg with mastercard gastritis diet . Thus, the development of clinically useful neuronal NOS inhibitors could provide a novel approach to indirectly controlling NMDA receptor-mediated transmission. As with agents directly acting at the NMDA receptor±channel complex, side-effects may preclude their use. LONG-TERM POTENTIATION The idea of retrograde messengers such as NO has also been advanced with regard to hippocampal LTP (Chapter 20). There is a marked lack of consensus on whether NO plays a role in LTP and much discussion on why different groups find different results. The importance of the need for a diffusible messenger in the initiation of long-term changes comes from the fact that LTP is induced by activation of postsynaptic NMDA receptors yet maintained by presynaptic changes. Thus, there is a requirement for a mediator to be generated by NMDA receptor activation and then diffuse back to the OTHER TRANSMITTERS AND MEDIATORS 285 presynaptic terminals. Unfortunately, some studies have shown that NOS inhibition blocks LTP whereas others have failed to show this. SUMMARY AND PERSPECTIVES NO differs from the more conventional NTs like the amino acids and monoamines in that it is not released from nerve terminals by arriving action potentials. It could be regarded as a second messenger except that its effects appear to be mediated by the production of cGMP, itself an established second messenger. The fact that its synthesis and release from neurons, and so its actions, are dependent on and stimulated by Ca2‡ influx, often after NMDA receptor activation, inevitably links NO to more extreme excitatory effects such as LTP, excitotoxicity, pain and possibly also epilepsy. Whether blocking its synthesis will be a more effective therapeutic approach than the use of NMDA receptor antagonists is problematic in that even if really specific NOS inhibitors are developed these effects will potentially be at least as widespread as block of NMDA receptors. Where NO inhibition may have the advantage is that it should only operate under conditions of NMDA action that are above normal and so may only affect adverse but not normal neuronal function. This should only occur in those brain areas and pathways showing that extreme level of activity. REFERENCES AND FURTHER READING Ash, ASF and Schild, HO (1966) Receptors mediating some actions of histamine. Bardoni, R, Goldstein, PA, Justin Lee, C, Gee, JG and MacDermott, AB (1997) ATP P2x receptors mediate fast synaptic transmission in the dorsal horn of the rat spinal cord. Baulieu, EE (1997) Neurosteroids: of the nervous system, by the nervous system, for the nervous system. Black, JW, Duncan, WAM, Durant, CJ, Ganellin, CR and Parsons, ME (1972) Definition and antagonism of histamine H2 receptors. Boulton, AA, Baker, GB, Dewhurst, NG and Sandller, M (Eds) (1984) Neurobiology of the Trace Amines, Humana Press, Totowa, NJ. Bredt, DS and Synder, SH (1994) Nitric oxide: a physiologic messenger molecule. Burnstock, G, Campbell, G, Satchell, D and Smythe, A (1970) Evidence that adenosine triphosphate or a related nucleotide is the transmitter substance released by non-adrenergic inhibitory nerves in the gut. Cox, B, Lee, TF and Martin, D (1981) Different hypothalamic receptors mediate 5-hydroxy- tryptamine and tryptamine induced core temperative changes in the rat. Dumuis, A, Sebben, M, Haynes, L, Pin, JP and Bockaert, J (1988) NMDA receptors activate the arachidonic acid cascade system in striatal neurons. Edwards, FA, Gibb, AJ and Colquhoun, D (1992) ATP receptor mediated synaptic currents in the central nervous system. Gasior, M, Carter, RB and Witkin, JM (1999) Neuroactive steroids: potential therapeutic use in neurological and psychiatric disorders. Grahame-Smith, DG (1971) Studies in vivo on the relationship between brain tryptophan, brain 5HT synthesis and hyperactivity in rats treated with a monoamine oxidase inhibitor and L- tryptophan. Greene, RN and Haas, HL (1991) The electrophysiology of adenosine in the mammalian central nervous system. Griffith, O and Stuehr, D (1995) NO synathases: properties and catalytic mechanisms.

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